Consent Forms

Consent forms are used to document patients' consent for certain procedures and in most cases is required for reimbursement.

 

Consent Forms
PHY-96-2 Certification and Documentation for Abortion (providers only) - Fillable - Updated 9/29/16  Note: On 10/26/16 changes were implemented to enable providers to upload or fax Abortion Consent Forms and supporting documentation via the Forms menu of the Web Portal. Effective November 28, 2016, Abortion Forms and supporting documentation received on paper will be returned to the provider.   See the October 2016 Provider Insider for details.
PHY-81243 Hysterectomy Consent (providers only) - Fillable - Updated 9/29/16   Note: On 10/26/16, changes were implemented to enable providers to upload or fax Hysterectomy Consent Forms and supporting documentation via the Forms menu of the Web Portal. Effective November 28, 2016, Hysterectomy Forms and supporting documentation received on paper will be returned to the provider.  See the October 2016 Provider Insider for details.
Form 193 Sterilization Consent (providers only) - Fillable - Updated 9/26/16   NNote: On 10/26/16 changes were implemented to enable providers to upload or fax Sterilization Consent Forms and supporting documentation via the Forms menu of the Web Portal.. Effective November 28, 2016, Sterilization Forms and supporting documentation received on paper will be returned to the provider.    See the October 2016 Provider Insider for details.
Form 193-I Instructions for Completing Sterilization Consent Form
193- Numbered Fields For Completing Sterilization Consent Form
193-F Packet Women's Sterilization Consent Educational Packet
193-M Packet Men's Sterilization Consent Educational Packet
Form 154 Agreement between Nursing Facility and Resident/Representative for Care
Form 392 Patient Consent Form for Hepatitis C Agents - 2/9/17
Form - Telemed Recipient Consent for Telemedicine Services - 11/2014  
Form 138-FP Family Planning Consent Form - Providers may use their own form as long as all required information is contained in the provider's form 
Form 175-FP Family Planning Home Visit (includes consent for visit by recipient) 
Form 388 Private Duty Nursing/Technology Assisted Waiver Agreement for Care
PHE-91-30-1 Biographical Data Sheet/Consent Form
Informed Consent Gateway to Community Living - Informed Consent With Options Counseling Form - For Case Managers